4.Year - Dental Medicine

1. Introduction to endodontics,pathohistological and clinical classification of pulpal diseases, indication and contraindication of endodontic treatment 4.Year - Dental Medicine

2. Pulp normality • histologic normality • clinical normality • The CLINICALLY NORMAL PULP • vital to testing procedures • responcive to a variety of excitations • free of spontaneous symptoms !!! • The MICROSCOPICALLY NORMAL PULP demonstrates only those histologic features that are compatible with its age. It is free of inflammatory change of any type!!!

3. Dental pulp - healthy

4. Dental pulp - inflamed, infected Acute pulpitis

5. Dental pulp DP : dental pulpOB : odontoblastD : dentinPD : predentinTF : Tom's fiber

6. The response of the pulp • The response of the pulp to injury or irritants occcur very soon, when the stimuly are mild • Pulpodentonal reactions occurs when chemical, mechanical, bacterial irritants attack the odontoblasts, namely Tome´s fibers, transmit a excitation to the pulp • The response of the pulp depends on the character and intensity of stimuly

7. A. Regresive changes B. Inflammatory changes Pulpal hyperemy Acute pulpitis Chronic pulpitis C. Necrosis of the pulp D. Gangraena of the pulp Acute pulpitis serose partial total purulent partial total Chronic pulpitis clausa a tergo granulomatosa interna aperta ulcerosa aperta hypertrophica Histopathologic classificationof pulpal diseases

8. A. Regresive changes • vacuolar degeneration of odontoblasts • hyalinic degeneration of the pulp • lipidic degeneration of the pulp • reticular atrophy • pathological calcification

9. Regresive changes:Vacuolar degeneration of odontoblasts • Odontoblasts react very quickly for many stimulies. • We can often find parts with vacuolization of odontoblasts. • This change can be result of pathologic damage of the pulp • It is the result of intracellular or extracellular break - down of cells metabolism

10. A. Regresive changes:Hyalinic degeneration of the pulp • In this regresiva change, we can find an albumenic substances in the pulp • This type of degeneratin is typical in teeth: • of old people • with chronic inflammation

11. Regresive changes:Lipidic degeneration of the pulpReticular atrophy • LIPIDIC DEGENERATION: • We can find it in pulp with chronic inflammation • It is break - down of metabolism, and the result is the lipids in cells • RETICULAR ATROPHY: • It is regresive change present in pulp of old people • Lost odontoblasts and pulpal cells are compensated by tissue

12. A. Regresive changes:Pathological calcification • Normal pulp doesn´t contain hard calcified substances • PULPAL DENTICUL - is hard, mineralisated substance located in the pulpal tissue • Usually in pulp we can find 1 - 12 denticuls • Sometimes they are small microscopic, sometimes biggist and they can fill pulp chamber or root canal, or obliterate it totally.

13. Clinical classificationof pulpal diseases 1. HEALTHY PULP: without clinical symptoms 2. REVERSIBLE FORM OF PULP INFLAMMATION: pulp with clinical symptoms, in which we can preserve the vitality of the pulp by treatment 3. IRREVERSIBLE FORM OF PULP INFLAMMATION: pulp with clinical symptoms, in which we cannot preserve the vitality of the pulp by treatment 4. DEATH OF THE PULP: pulp with lost vitality, necrotic, gangrenous

14. Symptoms typical forreversible process • pain present only for impulse, never spontaneous • patient can localize the pain • pain is of short duration, • analgetics stop the pain • Vitality test: short sensation, it leaves immediately • pain for percussion is never present • RTG: caries, filling next to the pulp tercial dentine is present periapical finding is negative

15. Symptoms typical forirreversible process • spontaneous pain through day, intervals without pain are shorter, intervals with pain start to be longer • pain through night is present • pain is neuralgiformic • analgetics do not stop the pain • Vitality test: attack of neuralgiformic painwhich leaves very slowly pulzating pain • patient cannot localize the tooth, sometimes even the jaw • pain for percussion is present, periapex is inflammed • RTG: caries, filling close to the pulp, or in pulp tercial dentine is not present

16. Right diagnosis How do the right diagnosis? • anamnesis • symptomatology • clinical examinations • knowlwdges of pathology of the pulp • clinical experiences • From all this points we make the clinical dg.: REVERSIBLE OR IRREVERSIBLE PULPAL DISEASE

17. Reversible or irreversible pulpal disease? • Reversible form of pulp inflammation turns into irreversible form of pulp inflammation - to pulpitis. In clinical practice this moment play the key role in decision of the TREATMENT CHOICE - • to treat hyperemia without pulpotomy or extirpation and preserve the pulp vitality or • to treat pulpitis as irreversible inflammation with endodontic treatment.

18. Reversible or irreversible pulpal disease? • The appropriate decision is not easy because the histologic changes are frequently not in correlation with the clinical symptoms. • for appropriate diagnosis we have clinical symptoms

19. Reversible or irreversible pulpal disease? B. INFLAMMATORY CHANGES: • Hyperemy • Acute pulpitis - acute serous partial pulpitis –––––––––––––––––––––––––––––––––––––––––––––– - acute serous total pulpitis - acute purulent partial pulpitis - acute purulent total pulpitis • Chronic pulpitis C. NECROSIS D. GANGRAENA reversible irreversible Endodontic

20. Endodontic treatment • What is endodontics? • Endodontics is the area of dentistry concerned with the prevention, diagnosis and treatment of disorders of the dental pulp • Years ago, such teeth with diseased or injured pulps were extracted. Today endodontic treatment offers a way for a safe and effective means of saving the teeth.

21. Considerations for endodontic therapy 1. Is the tooth needed or important? Does it have an opponent? Could it some day serve as an abutment for prosthesis? 2. Is the tooth salvageable, or is it so badly destroyed that it cannot be restored? 3. Is the entire dentition so completely broken down that it would be virtually impossible to restore? 4. Is the tooth serving esthetically, or would the patient be better served by its extraction and a more cosmetic replacement? 5. Is the tooth so severely involved periodontally that it would be lost soon for this reason? 6. Is the practitioner capable of performing the needed endodontic procedures?

22. Indications for endodontic therapy • Presence of irreversible pulpal disease • Prophylactic pulpal therapy which may be needed prior to other treatment procedures (restorative dentistry, prosthodontics & periodontics)

23. Contraindications forendodontic therapy The objections are listed according to: • status of the patient • dental reasons • local reasons • Status of the patient: • Age - past middle life • Health of the patient - DM, leukemia, terminal cancer, radiation necrosis, tuberculosis, syphilis ... • Too many treated pulpless teeth

24. Contraindications for endodontic therapy • Dental reasons: • Pulpless teeth are not salvageable if there are associated periapical and periodontal lesions • Local reasons: • the periapical lesion is an apical cyst • the tooth is badly broken down by caries • the involved tooth is badly fractured • the involved tooth has a mechanical root perforation • the involved tooth has perforating internal or external root resorption • the involved tooth is wholly or partially luxated

25. Contraindications for endodontic therapy • Severe, untreatable periodontal disease • Condition of remaining teeth • Non-restorable teeth • Extensive resorption • Vertical root fractures • Malpositioning of teeth • Limited accessibility • Non-strategic tooth • Aberrant root morphology • Unfavorable crown:root ratio • Predicatable failures • Proximity to vital structures

26. Thank you for attention !